Acceptance of a digital therapy recommender system for psoriasis.

BACKGROUND: About 2% of the German population are affected by psoriasis. A growing number of cost-intensive systemic treatments are available. Surveys have shown high proportions of patients with moderate to severe psoriasis are not adequately treated despite a high disease burden. Digital therapy recommendation systems (TRS) may help implement guideline-based treatment. However, little is known about the acceptance of such clinical decision support systems (CDSSs). Therefore, the aim of the study was to access the acceptance of a prototypical TRS demonstrator. METHODS: Three scenarios (potential test patients with psoriasis but different sociodemographic and clinical characteristics, previous treatments, desire to have children, and multiple comorbidities) were designed in the demonstrator. The TRS demonstrator and test patients were presented to a random sample of 76 dermatologists attending a national dermatology conference in a cross-sectional face-to-face survey with case vignettes. The dermatologist were asked to rate the demonstrator by system usability scale (SUS), whether they would use it for certain patients populations and barriers of usage. Reasons for potential usage of the TRS demonstrator were tested via a Poisson regression with robust standard errors. RESULTS: Acceptance of the TRS was highest for patients eligible for systemic therapy (82%). 50% of participants accepted the system for patients with additional comorbidities and 43% for patients with special subtypes of psoriasis. Dermatologists in the outpatient sector or with many patients per week were less willing to use the TRS for patients with special psoriasis-subtypes. Dermatologists rated the demonstrator as acceptable with an mean SUS of 76.8. Participants whose SUS was 10 points above average were 27% more likely to use TRS for special psoriasis-subtypes. The main barrier in using the TRS was time demand (47.4%). Participants who perceived time as an obstacle were 22.3% less willing to use TRS with systemic therapy patients. 27.6% of physicians stated that they did not understand exactly how the recommendation was generated by the TRS, with no effect on the preparedness to use the system. CONCLUSION: The considerably high acceptance and the preparedness to use the psoriasis CDSS suggests that a TRS appears to be implementable in routine healthcare and may improve clinical care. Main barrier is the additional time demand posed on dermatologists in a busy clinical setting. Therefore, it will be a major challenge to identify a limited set of variables that still allows a valid recommendation with precise prediction of the patient-individual benefits and harms.

[Measures and Recommendations for Ensuring Adequate Inpatient Care Capacities for Pandemic Management within a Region: Results of a Hybrid Delphi Method]. / Maßnahmen und Empfehlungen für die Sicherstellung adäquater stationärer Versorgungskapazitäten für das Pandemiemanagement innerhalb einer Region ­ Ergebnisse eines hybriden Delphi-Verfahrens.

INTRODUCTION: Since the beginning of the pandemic in spring 2020, inpatient healthcare has been under enormous burden, which is reflected especially in overworked staff, imprecise bed planning and/or data transfer. According to the recommendation of the Science Council, university clinics should play a controlling role in regional healthcare and act in conjunction with surrounding hospitals and practices. METHODS: In September 2021, 31 representatives from 18 university hospitals were invited to a hybrid Delphi study with a total of 4 survey rounds to discuss criteria for effective inpatient care in a pandemic situation, which were extracted from previous expert interviews. Criteria that were classified as very important/relevant by≥75% of the participants in the first round of the survey (consensus definition) were then further summarized in 4 different small groups. In a third Delphi round, all participants came together again to discuss the results of the small group discussions. Subsequently, these were prioritized as Optional ("can"), Desirable ("should") or Necessary ("must") recommendations. RESULTS: Of the invited clinical experts, 21 (67.7%) participated in at least one Delphi round. In an online survey (1st Delphi round), 233 criteria were agreed upon and reduced to 84 criteria for future pandemic management in four thematic small group discussions (2nd Delphi round) and divided into the small groups as follows: "Crisis Management and Crisis Plans" (n=20), "Human Resources Management and Internal Communication" (n=16), "Regional Integration and External Communication" (n=24) and "Capacity Management and Case & Care" (n=24). In the following group discussion (3rd Delphi round), the criteria were further modified and agreed upon by the experts, so that in the end result, there were 23 essential requirements and recommendations for effective inpatient care in a pandemic situation. CONCLUSION: The results draw attention to key demands of clinical representatives, for example, comprehensive digitization, standardization of processes and better (supra) regional networking in order to be able to guarantee needs-based care even under pandemic conditions. The present consensus recommendations can serve as guidelines for future pandemic management in the inpatient care sector.

Effectiveness of Digital Health Interventions Containing Game Components for the Self-management of Type 2 Diabetes: Systematic Review.

BACKGROUND: Games and game components have become a major trend in the realm of digital health research and practice as they are assumed to foster behavior change and thereby improve patient-reported and clinical outcomes for patients with type 2 diabetes. OBJECTIVE: The aim of this systematic review was to summarize and evaluate the current evidence on the effectiveness of digital health interventions containing game components on behavioral, patient-reported, and clinical outcomes for patients with type 2 diabetes. METHODS: An electronic search was conducted in MEDLINE and PsycINFO in April 2020; updated in April 2022; and supplemented by additional searches via Google Scholar, Web of Science (which was used for forward citation tracking), and within the references of the included records. Articles were identified using predefined inclusion and exclusion criteria. In total, 2 reviewers independently conducted title, abstract, and full-text screening and then individually performed a critical appraisal of all the included studies using the Cochrane risk-of-bias tool version 2. A consensus was reached through discussion. RESULTS: Of 2325 potentially relevant titles (duplicates excluded), 10 (0.43%) randomized controlled trials were included in this review. Quality assessment revealed a high risk of bias for all randomized controlled trials except for 10% (1/10), with performance bias due to the lack of blinding being the major source of bias. There is evidence suggesting that digital health interventions containing game components can substantially improve motivation for physical activity (1/1, 100% of the studies dealing with PA motivation), exercise intensity (3/5, 60%), dietary behavior (4/4, 100%), health literacy (1/3, 33%), mental quality of life (2/2, 100%), glycated hemoglobin level (2/6, 33%), BMI (1/3, 33%), fasting plasma glucose level (1/2, 50%), waist circumference (1/1, 100%), and aerobic capacity (1/1, 100%). CONCLUSIONS: Published studies indicated that digital health interventions containing game components might improve health behavior patterns, quality of life, and clinical outcomes in patients with type 2 diabetes. However, the intervention types and outcomes studied were heterogeneous, and study quality was mostly low, which translates to ambiguous results. Future research should focus on sound methodology and reporting as well as on identifying game components that contribute to significant positive effects. TRIAL REGISTRATION: PROSPERO CRD42020209706; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=209706.

[Mixed Methods Studies in Health Services Research: Requirements, Challenges and the Question of Integration - a Discussion Paper from the Perspective of Qualitative Researchers]. / Mixed Methods-Studien in der Versorgungsforschung: Anforderungen, Herausforderungen und die Frage der Integration ­ ein Diskussionspapier aus der Perspektive qualitativ Forschender.

With this discussion paper, the subgroup Mixed Methods of the working group Qualitative Research Methods in the non-profit organization German Network Health Services Research (DNVF) is taking up the topic of three previous discussion papers on the significance and potentials of qualitative research methods in health services research. Mixed methods are being increasingly used and demanded in health services research. However, there are also areas of conflict in the planning and implementation of mixed methods studies, and these are addressed in this paper from the perspective of qualitative research. Special attention is given to the aspect of integration as the fundamental signature of mixed methods research. With this discussion paper, our aim was to stimulate critical as well as constructive exchange of ideas on what constitutes high-quality health services research characterised by a diversity of methods and the framework conditions under which this can succeed.

The telemedicine community readiness model-successful telemedicine implementation and scale-up.

To successfully scale-up telemedicine initiatives (TIs), communities play a crucial role. To empower communities fulfilling this role and increase end users' acceptance of TIs, support tools (from now on entitled artifacts) are needed that include specific measures to implement and scale up telemedicine. Addressing this need, the article introduces the Telemedicine Community Readiness Model (TCRM). The TCRM is designed to help decision-makers in communities to create a favorable environment that facilitates the implementation and scale-up of TIs. The TCRM is a practical tool to assess communities' readiness to implement TIs and identify aspects to improve this readiness. The development process follows a design-science procedure, which integrates literature reviews and semi-structured expert interviews to justify and evaluate design decisions and the final design. For researchers, the paper provides insights into factors that influence telemedicine implementation and scale-up (descriptive role of knowledge) on the community level. For practitioners, it provides a meaningful tool to support the implementation and scale-up of TIs (prescriptive role of knowledge). This should help to realize the potential of telemedicine solutions to increase access to healthcare services and their quality.

[Development, Evaluation and Implementation of Digital Health Interventions (Part 1) - Discussion Paper of the Digital Health Working Group of the German Network for Health Services Research (DNVF)]. / Digitale Gesundheitsinterventionen entwickeln, evaluieren und implementieren (Teil I) ­ Diskussionspapier der Arbeitsgruppe Digital Health des Deutschen Netzwerk Versorgungsforschung (DNVF).

The development and application of digital interventions in health-related topics are gaining momentum in health service research. Digital interventions are often complex and need to be evaluated and implemented in complex settings. Due to their characteristics, this poses methodological challenges for health services research that have to be identified and addressed. Hence, the Working Group on Digital Health of the German Network for Health Services Research (DNVF) has prepared a discussion paper. This paper discusses methodological, practical and theoretical challenges associated with the development and evaluation of digital interventions from the perspective of health services research. Possible solutions are suggested and future research needs to address these methodological challenges are identified.

[Developing, Evaluating and Implementing Digital Health Interventions Part II - Discussion Paper of the Digital Health Working Group of the German Network for Health Services Research (DNVF)]. / Digitale Gesundheitsinterventionen entwickeln, evaluieren und implementieren Teil II ­ Diskussionspapier der Arbeitsgruppe Digital Health des Deutschen Netzwerk Versorgungsforschung (DNVF).

The methodological challenges of evaluating digital interventions (DI) for health services research are omnipresent. The Digital Health Working Group of the German Network for Health Services Research (DNVF) presented and discussed these challenges in a two-part discussion paper. The first part addressed challenges in definition, development and evaluation of DI. In this paper, which represents the second part, the definition of outcomes, reporting of results, synthesis of evidence, and implementation are addressed as methodological challenges of DI. Potential solutions are presented and the need to address these challenges in future research are discussed.

Sauerbruch, STARPAHC, and SARS: Historical Perspectives on Readiness and Barriers in Telemedicine.

Aim: Telemedicine is a promising solution to extend traditional health care services. Even though mainly discussed during the past two decades, its roots go back into the past century and even further, considering the use of bonfires to warn other villages of diseases. Insights from historical cases can therefore be useful for the ongoing discussion regarding the successful implementation of telemedicine. Subject and Methods: We analyzed three historical telemedicine cases (varying regarding time and place) and extracted their success factors and barriers as well as assessed their maturity by using the Telemedicine Community Readiness Model (TCRM). Evidence-based categories of success factors and barriers as well as the TCRM's dimensions were used as deductive categories to analyze the study material's content. Results: The analysis showed that the readiness for telemedicine is higher when the technology is the only option to access health care services. In all three cases, core readiness played a central role. However, the health sector, existing technology, and finance were barriers present at all times, while during pandemics, some barriers are only temporarily removed, for example, by putting legal issues on hold. The analyzed cases were all on lower levels of maturity as they mainly represent pilot tests or exceptional circumstances. Conclusion: Results indicate the important core functions in telemedicine initiatives as well as the diversity of their circumstances. Insights from such historical meta-perspectives can, for example, help to strengthen the sustainability of the increased use of telemedicine during the COVID-19 pandemic and scale up current telemedicine projects.

Tackling the scaling-up problem of digital health applications.

AIM: The purpose of this editorial is to provide guidance for the readers concerning the broad realm of approaches towards successful implementation of digital health applications into the health care system. Recent developments due to the challenges posed by the COVID-19 pandemic are used as a current angle. SUBJECT AND METHODS: All contributions within the special issue were scanned for their most decisive contribution to the special issue and the field of implementation science, with a focus on digital health. Micro, meso, and macro layers of implementation processes, as well as the technological perspective itself, are used as broad categories for sorting the contributions and structuring the special issue. RESULTS: The ten contributions to this special issue cover micro (n = 1), technology (n = 1), meso (n = 4) and macro (n = 2) perspectives on the implementation process of digital health applications. Two further contributions also tackle the issue from a wider perspective when aiming to structure telemedicine application types and barriers encountered when implementing digital health. CONCLUSION: Considering the wide array of research fields represented in this special issue, an emphasis is put on the importance of interdisciplinary work required for tackling the scale-up problem of digital health. As such, the special issue can assist in leveraging the full potential of digital health, not only when dealing with situations as out-of-the-ordinary as the current pandemic but also well beyond that, for example when dealing with the upcoming challenges of demographic change.

Long-Term Effects of a Video-Based Smartphone App ("VIDEA Bewegt") to Increase the Physical Activity of German Adults: A Single-Armed Observational Follow-Up Study.

As physical inactivity is one of the four leading risk factors for mortality, it should be intensively treated. Therefore, this one-year follow-up study aimed to evaluate the long-term effects of a preventive app to increase physical activity in German adults under real-life circumstances. Data collection took place from July 2019 to July 2021 and included six online questionnaires. Physical activity was studied as the primary outcome based on MET-minutes per week (metabolic equivalent). Secondary outcomes included health-related quality of life based on a mental (MCS) and physical health component summary score (PCS). At the time of publication, 46/65 participants completed the study (median 52 years, 81.5% women). A significant increase of physical activity was observed in people with a low/moderate baseline activity during the first four months of follow-up (median increase by 490 MET-minutes per week, p < 0.001, r = 0.649). Both MCS (median increase by 2.8, p = 0.006, r = 0.344) and PCS (median increase by 2.6, p < 0.001, r = 0.521) significantly increased during the first two months and the BMI significantly decreased during the first six months after the intervention (median decrease by 0.96 kg/m2, p < 0.001, r = 0.465). Thus, this study provides evidence for the medium-term impact of the app, since the effects decreased over time. However, due to the chosen study design and a sizeable loss to follow-up, the validity of these findings is limited.

[The role of university hospitals in regional health care management for coping with the COVID-19 pandemic]. / Die Rolle der Universitätskliniken im regionalen medizinischen Versorgungsmanagement zur Bewältigung der COVID-19 Pandemie.

INTRODUCTION: The complex and dynamic situation in the current pandemic requires a regionally coordinated and interconnected cooperation between the different stakeholders within the health care system, such as the inpatient sector or the public health service. The aim of this study is to analyze health care management during the COVID-19 pandemic in 2020 with a focus on regional networking and communication structures. METHODS: As part of the BMBF-funded project "egePan Unimed", an online questionnaire on pandemic management was sent to the boards of all 35 German university hospitals in November 2020. The questionnaire focused on the core topics of regional networking, crisis management, data exchange, and communication with political stakeholders. The questionnaire consisted of 37 closed and three open-ended questions. After piloting, the invitation to the survey was extended three times by mail and once by telephone. RESULTS: The results (n=25, response 71.4%) show that 68% of the clinics surveyed were connected to representatives from the inpatient sector and 86% to representatives from the public health service. Networking with representatives from the outpatient sector was less common (26%). Of the university hospitals surveyed, 84% had a leadership role in a regional COVID-19 pandemic management effort. Data exchange with regional hospitals in the course of pandemic management took place at 75% of the participating university hospitals and with supra-regional hospitals at 67% of the clinics surveyed. CONCLUSION: To manage regional medical care during the COVID-19 pandemic in 2020, university hospitals often assumed a coordinating role in the complex pandemic care process. There were often structured collaborations with regional clinics and health departments and comparatively few cooperations with the outpatient care sector. However, this cooperation has the potential to prevent overcrowding in hospitals.

Evaluation of a flexible and integrative psychiatric care model in a department of child and adolescent psychiatry in Tübingen, Germany: study protocol (EVA_TIBAS).

BACKGROUND: Model projects for flexible and integrated treatment (FIT) in Germany aim at advancing the quality of care for people with mental disorders. A new FIT model project was established in 2017 at the Department of child and adolescent psychiatry (KJP) of the University Hospital Tübingen (Universitätsklinikum Tübingen, UKT). The study design of EVA_TIBAS presented here describes the evaluation of the FIT model project at the KJP of the UKT. This evaluation aims at quantifying the anticipated FIT model project changes, which are to improve patients' cross-sectoral care at the same maximum cost as standard care. METHODS: EVA_TIBAS is a controlled cohort study using a mix of quantitative and qualitative methods. The FIT evaluation consists of three modules. In Module A, anonymized claims data of a statutory health insurance fund will be used to compare outcomes (duration of inpatient and day care psychiatric treatment, inpatient and day care psychiatric length of stay, outpatient psychiatric treatment in hospital, inpatient hospital readmission, emergency admission rate, direct medical costs) of patients treated in the model hospital with patients treated in structurally comparable control hospitals (estimated sample size = ca. 600 patients). In Module B, patient-reported outcomes (health related quality of life, symptom burden, return to psychosocial relationships (e.g. school, friends, hobbies), treatment satisfaction, societal costs) will be assessed quantitatively using validated questionnaires for the model and two control hospitals (estimated sample size = ca. 300 patients). A subsequent health economic evaluation will be based on cost-effectiveness analyses from both the insurance fund's and the societal perspective. In Module C, about 30 semi-structured interviews will examine the quality of offer, effects and benefits of the service offered by the social service of the AOK Baden-Württemberg (for stabilizing the overall situation of care in the family) in the model hospital. A focus group discussion will address the quality of cooperation between employees of the university hospital and the social services. DISCUSSION: The results of this evaluation will be used to inform policy makers whether this FIT model project or aspects of it should be implemented into standard care. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov PRS (ID: NCT04727359 , date: 27 January 2021).

Non-use of telemedicine: A scoping review.

Many telemedicine interventions fail to be implemented in medical care with non-use and discontinued use by patients being among the major reasons. The aim of this scoping review was to provide an overview of barriers associated with non-use and discontinued use of telemedicine. An electronic search was conducted in Pubmed in October 2019 and updated in November 2020, followed by a hand search in the beginning of 2021. All potential articles were screened by two independent reviewers based on predefined inclusion and exclusion criteria. A qualitative content analysis according to Mayring was carried out. The topics 'intervention', 'context of use' and 'user' were chosen as overarching themes. Out of 1377 potentially relevant articles, 73 were included. User-related barriers were mentioned in most of the analysed studies, followed by barriers related to the intervention. The analysis provides the basis for overcoming non-use issues in telemedicine.

Use of Patient-Reported Outcome Measures and Patient-Reported Experience Measures Within Evaluation Studies of Telemedicine Applications: Systematic Review.

BACKGROUND: With the rise of digital health technologies and telemedicine, the need for evidence-based evaluation is growing. Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are recommended as an essential part of the evaluation of telemedicine. For the first time, a systematic review has been conducted to investigate the use of PROMs and PREMs in the evaluation studies of telemedicine covering all application types and medical purposes. OBJECTIVE: This study investigates the following research questions: in which scenarios are PROMs and PREMs collected for evaluation purposes, which PROM and PREM outcome domains have been covered and how often, which outcome measurement instruments have been used and how often, does the selection and quantity of PROMs and PREMs differ between study types and application types, and has the use of PROMs and PREMs changed over time. METHODS: We conducted a systematic literature search of the MEDLINE and Embase databases and included studies published from inception until April 2, 2020. We included studies evaluating telemedicine with patients as the main users; these studies reported PROMs and PREMs within randomized controlled trials, controlled trials, noncontrolled trials, and feasibility trials in English and German. RESULTS: Of the identified 2671 studies, 303 (11.34%) were included; of the 303 studies, 67 (22.1%) were feasibility studies, 70 (23.1%) were noncontrolled trials, 20 (6.6%) were controlled trials, and 146 (48.2%) were randomized controlled trials. Health-related quality of life (n=310; mean 1.02, SD 1.05), emotional function (n=244; mean 0.81, SD 1.18), and adherence (n=103; mean 0.34, SD 0.53) were the most frequently assessed outcome domains. Self-developed PROMs were used in 21.4% (65/303) of the studies, and self-developed PREMs were used in 22.3% (68/303). PROMs (n=884) were assessed more frequently than PREMs (n=234). As the evidence level of the studies increased, the number of PROMs also increased (τ=-0.45), and the number of PREMs decreased (τ=0.35). Since 2000, not only has the number of studies using PROMs and PREMs increased, but the level of evidence and the number of outcome measurement instruments used have also increased, with the number of PREMs permanently remaining at a lower level. CONCLUSIONS: There have been increasingly more studies, particularly high-evidence studies, which use PROMs and PREMs to evaluate telemedicine. PROMs have been used more frequently than PREMs. With the increasing maturity stage of telemedicine applications and higher evidence level, the use of PROMs increased in line with the recommendations of evaluation guidelines. Health-related quality of life and emotional function were measured in almost all the studies. Simultaneously, health literacy as a precondition for using the application adequately, alongside proper training and guidance, has rarely been reported. Further efforts should be pursued to standardize PROM and PREM collection in evaluation studies of telemedicine.

Evaluation is Key: Providing Appropriate Evaluation Measures for Participatory and User-Centred Design Processes of Healthcare IT.

INTRODUCTION: The increasing availability of healthcare IT has the potential to improve the integration of health services. Existing projects developing healthcare IT mostly disregard the potential and importance of incorporating user feedback and proper evaluation measures to gain user feedback throughout the development process. We therefore provide methodological guidance for evaluation in a stepwise user-centred design process. METHODS: Based on a literature review we propose adequate methods for data collection in each phase of participatory and user-centred healthcare IT development. In order to provide an orientation within the plethora of development processes used in practice, we consolidate a generic blueprint process from the literature review. The applicability of our methodological guidance is shown in three diverse use cases from the field of integrated care. RESULTS: From 14 literature items, we identified common evaluation methods including, among others, interviews, focus groups, and surveys. These methods can be associated to six typical development phases that could be derived from research: State of the Art Research, Requirement Analysis, Conceptual Prototype, Preliminary Prototype, Full Prototype, Full Application. The use cases demonstrate the value of qualitative methods and mixed methods designs. DISCUSSION: Our methodological guidance has proven applicable for designing healthcare IT solutions from scratch - both for patient and professional settings - and to develop a platform for combining existing component-based solutions. In integrated care settings, where a wide range of stakeholders with multiple needs exist, we thus provide methodological guidance on how to involve users in the development process. CONCLUSION: Our stepwise methodological guidance helps to design and properly evaluate healthcare IT solutions, which meet the user needs and requirements, for integrated care settings.

Prenatal Methamphetamine Exposure: Effects on Child Development­A Systematic Review.

BACKGROUND: In Germany, the 12-month prevalence of methamphetamine use among persons aged 15 to 34 is 1.9%. An increasing number of newborns are being born after a prenatal methamphetamine exposure (PME). In 2014, in the German state of Saxony, approximately four out of 1000 newborns were affected. METHODS: This systematic review (Prospero registration number CRD42017060536) includes publications that were published between January 1990 and November 2019. The purpose was to determine the effects of PME on the peri- and neonatal condition of the affected children and on their further long-term development. Observational studies with a control group were included in the review and examined for their methodological quality. RESULTS: 31 publications, which dealt with two prospective and six retrospective cohort studies, were included in the review. The studies involved a total of 4446 mother-child pairs with PME, compared with 43 778 pairs without PME. A metaanalysis revealed that PME was associated with, among other findings, lower birth weight (SMD = -0.348; 95% confidence interval [-0.777; 0.081]), shorter body length (SMD= -0.198 [-0.348; -0.047]), and smaller head circumference (SMD= -0.479 [-1.047; 0.089]). Some differences between the groups with and without PME persist into the toddler years. Moreover, children with PME much more commonly display psychological and neurocognitive abnormalities, which are more severe in children growing up in problematic surroundings (discord, violence, poverty, low educational level of the parent or caregiver). A limitation of this review is that not all studies employed an objective or quantitative measure of methamphet - amine use. CONCLUSION: The documented effects of PME on child development necessitate early treatment of the affected expectant mothers, children, and families. Emphasis should be placed on structured and interdisciplinary preventive measures for methamphetamine use.

Implementing longitudinal integrated curricula: Systematic review of barriers and facilitators.

PURPOSE: The increase of longitudinal integrated curricula in medical schools worldwide represents the shift towards an outcome-oriented education. This novel model allows comprehensive student-patient interactions over time and integrates the educational content across disciplines. According to quantitative research, students, patients, doctors and communities benefit from this educational model in terms of participant satisfaction, learning outcomes and clinician recruitment. However, quantitative research does not provide detailed information on programme implementation processes. Therefore, this review aims to summarise facilitators and barriers of programme implementation reported in qualitative and mixed methods studies. METHOD: The authors reviewed the literature about facilitators and barriers for the implementation of longitudinal integrated curricula in undergraduate medical education programmes. The systematic search was conducted in MEDLINE, Embase and PsycINFO on 2 December 2019. The authors used the CASP checklist for qualitative research for the critical appraisal and summarised the results across studies using thematic content analysis. RESULTS: The authors screened 1682 reports. Twenty studies examining 17 different curricula met the inclusion criteria. Most curricula were implemented in the United States (n = 6/17), Australia (n = 5/17) or Canada (n = 4/17). Programme implementation is facilitated and hampered by its educational components (eg continuity of supervision, safe learning environments), organisational structures (eg community involvement) and participating students' and staff' motivation and personality. The critical appraisal revealed that several studies lacked transparent documentation and adequate reflection on the researcher-participant relationship (n = 20/20), data collection instruments (n = 12/20) and recruitment strategy (n = 4/20). CONCLUSIONS: The authors derived practical recommendations for the implementation of undergraduate, patient-centred, integrated medical curricula. Programme managers need to define and communicate common objectives with all participants. They should clarify the implementation of the objectives in all processes in a transparent and structured manner. Considering reporting guidelines, future studies in this field should document more transparently the methods used to gain qualitative insights and the researchers' personal involvement.

A qualitative study of users' experiences after 3 months: the first Rwandan diabetes self-management Smartphone application "Kir'App".

BACKGROUND: Owing to the increasing popularity of smartphones in Rwanda, almost 75% of the entire population currently has access to the internet. Although it has been shown that smartphone applications can support diabetes self-management, there was no diabetes self-management application available in Rwanda until April 2019. Based on the findings of a prior study assessing the needs and expectations of potential users, 'Kir'App' was developed to fill that void. The aim of this study was to evaluate users' experiences after 3 months of use of the first Kir'App prototype. METHODS: The participants of the previous study were recruited to take part in the current study. Semi-structured, in-depth, face-to-face interviews were conducted. Findings were analysed thematically using Mayring's method of qualitative content analysis. Both deductive and inductive approaches were used to analyse transcripts according to the original categories and subcategories of the previous study. RESULTS: A total of 14 people with either type 1 or type 2 diabetes participated in the study. Age of participants ranged from 19 to 70 years, with a mean age of 34.4 years. Seven of the eight original themes and one additional theme were subjoined: diabetes education and desired information provision; increased diabetes knowledge and awareness; monitoring and reminder functions; nutrition; physical activity; coping with burden of disease; app features; use behaviour and usability. Overall, participants stated that the app increased their diabetes knowledge and assisted them with their diabetes self-management. CONCLUSIONS: We found that the first prototype of Kir'App meets the overall needs and expectations of participating Rwandan diabetics. Having followed a strict user-centred design process, their qualitative insights will help to further improve the app.